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Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use

Archive for 2019 Performance Period

Last updated: May 16, 2019

CMS Measure ID: CMS169v7
Version: 7
NQF Number: Not Applicable
Measure Description:

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use

Initial Patient Population:

Patients 18 years of age or older at the start of the measurement period with a new diagnosis of unipolar depression or bipolar disorder during the first 323 days of the measurement period, and evidence of treatment for unipolar depression or bipolar disorder within 42 days of diagnosis. The existence of a 'new diagnosis' is established by the absence of diagnoses and treatments of unipolar depression or bipolar disorder during the 180 days prior to the diagnosis.

Denominator Statement:

Equals Initial Populationinfo-icon

Denominator Exclusions:

None

Numerator Statement:

Patients in the denominatorinfo-icon with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosis

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare & Medicaid Services (CMS)
Domain: Effective Clinical Care
Previous Version:
Measure Scoring: Proportion
Measure Type: Process
Improvement Notation:

Higher score indicates better quality

Guidance:

The intent of the measure is that the assessment be performed for a single episode for each patient. Due to current limitations of the eMeasure specificationinfo-icon system, it is possible for there to be up to two treatment episodes per patient, identified through up to two index episodes. As a result, the numeratorinfo-icon criteria of this measure can be satisfied if a substance use assessment is performed within either treatment episode. Future versions of the measure should address this issue.

A BH Outpatient Psychotherapy encounter meets the intent of both an encounter and a treatment.

Notes: Removed from Quality Payment Program
Quality ID: 367
Meaningful Measure: Prevention, Treatment, and Management of Mental Health

Specifications

Release Notes

Header

  • Updated Version Number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

Logic

  • Added supplemental timing attributes to most datatypes in QDM 5.3 to facilitate accurate retrieval of time related information within CQL logic. Timing attributes now include a time interval, such as prevalence period or relevant period, and/or actual time of documentation with Author Datetime. Relevant period is the general method to describe start and stop times for datatypes. Prevalence period is used for some datatypes to more accurately define onset and abatement times.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Assigned cardinality to each attribute to be more explicit in guiding specificationinfo-icon and implementation of QDM data elements. Cardinality refers to the number of instances of the attribute that can be included in the measure description. Cardinality for most attributes is 0.. 1 (i.e., can occur up to 1 time), but some attributes have a cardinality of 0.. * (i.e., can occur multiple times).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • CQL libraries contain sets of CQL definitions, or CQL expression statements. A context statement, patient or population, can now be used in a CQL library to clearly establish how the subsequent list of CQL expressions will be interpreted. A 'Population' context will interpret the CQL expression with reference to the entire population of the item being counted, patients or encounters. A 'Patient' context will interpret the CQL expression with reference to a single patient. Context statements are not required, but one or more context statements may be used within a library to help clarify how the CQL expressions will be interpreted. Patient context is the default if none is specified.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Replaced measure-defined definitions with similar definitions and functions from CQL shared libraries for consistency across measures.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated measure logic from Quality Data Model (QDM)info-icon-based logic to Clinical Quality Language (CQL)info-icon-based logic. Information on CQL can be found at the eCQI Resource centerinfo-icon (https://ecqi.healthit.gov/cql). Information about specific versions of the new standards in use for CMS reporting periods can be found at the eCQI Resource Center (https://ecqi.healthit.gov/ecqm-tools-key-resources). Switching from QDM to CQL brings with it many changes, as well as enhanced expression capability, but only those changes with significant impact will be outlined in technical release notes. For example, in the case of timing operators, changes may only be summarized if those changes impact the measure calculation.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Setinfo-icon

The VSACinfo-icon is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 11 SOP codes (299, 32127, 32128, 391, 517, 524, 614, 621, 622, 623, 629) and deleted 3 SOP codes (63, 64, 69).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set BH Antidepressant Medication (2.16.840.1.113883.3.1257.1.972): Added 1 RXNORM code (803293) and deleted 2 RXNORM codes (245373, 246588).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set BH Outpatient encounter (2.16.840.1.113883.3.464.1.49): Added 7 SNOMEDCT codes (185463005, 185464004, 185465003, 281036007, 3391000175108, 439740005, 77406008).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • OID (2.16.840.1.113883.3.1257.1.1604): Consolidated single code extensional value set 2.16.840.1.113883.3.1257.1.1604) into extensional value set (2.16.840.1.113883.3.1257.1.1819) to eliminate a single code value set. Value sets have the same purpose.

    Measure Section: QDM Data Elements

    Source of Change: Measure Lead

  • Value set Payer (2.16.840.1.114222.4.11.3591): Deleted 1 SOP code (24).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

  • Value set BH Antidepressant Medication (2.16.840.1.113883.3.1257.1.972): Deleted 4 RXNORM codes (730440, 730441, 730442, 803293).

    Measure Section: QDM Data Elements

    Source of Change: 2019 Addendum

External Resources